Trauma Care : Centers Save Lives--Yet Draw Foes

On a rainy night last year, a speeding auto slammed broadside into Lainie Niemeyer’s small car as she drove in the South Bay. The bone-crunching collision bloodied her from head to foot, with brain, chest, belly and leg injuries.

Unconscious and barely breathing, Niemeyer was pried out of the wreckage and whisked into the emergency room of a nearby hospital. Miraculously, the 20-year-old student recovered. But her survival was due more to a fluke of geography than medical expertise.

For the paramedics who rescued Niemeyer knew better than to rush her to the closest hospital. Instead, they took her to a Los Angeles County trauma center where surgeons and other specialists treated her catastrophic injuries on a moment’s notice.

Niemeyer beat the odds. If her accident had occurred almost anywhere else in the country--where there are few trauma centers offering such immediate, life-saving care--she or any other person with similar injuries might have died.

Needless Deaths

Across the nation today, from rural towns and suburban communities to large cities, an estimated 15,000 trauma victims like Niemeyer die needlessly every year from injuries suffered in car accidents, shootings, stabbings and industrial accidents, according to trauma experts.

Many of these patients simply bleed to death from non-lethal injuries--such as torn livers, ruptured spleens and lacerated kidneys--while waiting for surgeons to arrive. Others die when medical teams fail to recognize the signs of internal bleeding.

“These are people who would be alive if they had received prompt treatment,” said Dr. John West, an Orange County surgeon and outspoken trauma care proponent. “What you have here is a national tragedy that repeats itself every day.”

It is not for lack of medical knowledge. Military doctors, based on experiences in Vietnam and Korea, have long known that badly injured soldiers who are rushed into special surgical units--like the MASH outfit popularized on television--have the best chance of surviving.

Blocked by Doctors

But the lesson has been slow to spread. In recent years, despite hard evidence that a nationwide trauma system could be saving thousands of lives, many doctors and hospital administrators have blocked the growth of such programs.

Ironically, few of these opponents doubt that such care is necessary. But financial pressures, hospital turf wars and clashing views on emergency medicine have caused many officials to fight the expansion of trauma programs.

Some hospitals, for example, fear losing affluent patients--and profits--to specialized trauma centers. Others believe they can treat victims just as well, and resent being perceived as second-rate hospitals.

A few physicians are skeptical that such programs really work, while a multitude say that trauma care is simply too expensive to offer in many parts of the country.

Whatever the reason, “the biggest loser of all is the American consumer,” said Dr. Richard Cales, director of emergency medicine at Portland Adventist Hospital and a national expert on trauma care.

“The life or death of a motorist can hinge on the medical politics of the community he happens to be in when an accident occurs,” he said. “In this day and age, that’s unacceptable.”

The grim statistics of preventable trauma deaths cut across income and racial lines, affecting every region of the country:

-In Fort Lauderdale, Fla., paramedic Darrell Page was injured in a 1983 bike accident and lay for two hours in a community hospital while surgeons finished a routine operation. He bled to death from a torn liver as he was being wheeled into the emergency room. Page’s death sparked a bitter controversy in the community, which has not implemented trauma programs.

-In Chicago, Ben Wilson, a nationally known high school basketball player, was shot last November as he left school. At the hospital, he waited two hours before going into surgery, and later died from massive internal bleeding. Several Chicago surgeons said privately that Wilson could have survived if the city required paramedics to take patients to trauma centers.

-In the San Francisco Bay Area, 32-year-old Eugene Barnes was taken to a non-trauma hospital in Contra Costa County earlier this year with stab wounds to the head. He lay bleeding for four hours while doctors tried to find a neurosurgeon to treat him. Barnes finally was airlifted to San Francisco General Hospital, where he died after surgery. A spokesman at the Contra Costa County hospital said Barnes’ case shows the need for greater regulation of emergency medical care.

Scarce Facilities

Trauma programs are scarce outside Southern California--including Los Angeles, Orange, San Diego, Riverside and San Bernardino counties--San Francisco County, the state of Maryland and hospitals in scattered cities and suburban communities across the nation.

A driver seriously injured in Los Angeles or San Francisco, for example, has a reasonable certainty of being taken to a trauma center. But the same driver would have no such assurances the minute he drives north across the Los Angeles County border, or over the San Francisco Bay Bridge into the East Bay counties.

Almost 85% of the nation is “unprotected” by such medical care, according to West and other advocates. And the prognosis for a national system of trauma centers is not encouraging.

Congress, prodded by the Reagan Administration, in 1982 cut off direct financing to a program that sought to develop such nationwide care. Left to themselves, few states have adopted such programs. Only a handful of local governments have tried.

Meanwhile, the nation has focused most of its attention on diseases like AIDS, cancer and heart failure. Trauma care--which offers few chances for research breakthroughs--attracts only a fraction of the federal and private dollars that go to other medical needs.

Yet it has become one of the nation’s most serious health problems. Trauma deaths and injuries were called “the neglected epidemic of modern society” in a 1966 report by the National Academy of Sciences. A follow-up study this year reached the same conclusion.

Each year, an estimated 160,000 Americans die from traumatic injuries, according to federal studies. Trauma, which primarily affects the young, robs people of more working years of life than cancer and heart disease combined.

$61-Billion Cost

The costs of this epidemic are staggering: The yearly bill for those who die from trauma as well as the estimated 8 million Americans who suffer traumatic injuries is $61 billion, according to a report in the Journal of Trauma.

While trauma kills more Americans under the age of 38 than all diseases combined, it does not just haunt the young. President Reagan, perhaps the nation’s most famous trauma patient, was rushed into surgery at the George Washington University Hospital trauma center 35 minutes after being shot outside a Washington hotel in 1981.

The quick action by Reagan’s medical team is credited with saving his life. Today, many doctors believe that all Americans have a right to that same care.

“Trauma care is not a secret anymore,” said Dr. Joseph Giordano, the chief surgeon who operated on Reagan. “Enough communities around the country know about it now, so if they haven’t begun to upgrade their care it’s by their own default.”

How exactly does a trauma program work? Unlike many hospitals, trauma centers are staffed around the clock with surgical teams and specialists who can begin operating on victims within minutes. They are trained to spot danger signs such as internal bleeding that other physicians might overlook.

These hospitals are linked by radio to paramedics in the field who identify the most seriously injured. Ideally, victims should reach trauma centers within 15 to 20 minutes of paramedics arriving at the scene.

Lainie Niemeyer, for example, was rushed to Daniel Freeman Memorial Hospital in Inglewood, where a waiting surgeon and trauma team immediately stabilized her breathing, determined the extent of her injuries and took her into an operating room to stop the bleeding from her torn spleen and kidney.

“This woman’s care was quite dramatic, in that when she came in she was not breathing very well,” said Dr. Mitchell Major, a Daniel Freeman anesthesiologist. “If the blood hadn’t been taken out of her lung there is no question that she would not have survived, not even long enough to get to the operating room.”

In all, 11 specialists swarmed around Niemeyer’s gurney when it burst into the emergency room at 10:19 p.m., including a surgeon, anesthesiologist, X-ray technician, emergency room physician, nurses and lab personnel, said Dr. George Stepanic, the trauma center director.

By contrast, at most non-trauma hospitals and neighborhood walk-in clinics, badly injured patients can wait hours while physicians try to round up surgeons and other specialists. Some patients are transferred from one hospital to another in a time-consuming search for care.

The difference is crucial--but it is not an issue of good hospitals versus bad hospitals, trauma care advocates say.

Costly Waits

“You can have the best hospital in the world with the greatest surgeons in the world, and somebody can still come in with a ruptured liver and bleed to death in your emergency room while you’re waiting for the doctor to come in from the golf course,” said Dr. Brent Eastman, trauma director of Scripps Memorial Hospital in La Jolla.

Numerous medical studies on so-called preventable deaths have shown that patients who died in regular hospitals and emergency clinics could have been saved at trauma centers.

West, for example, has authored several nationally acclaimed studies on the subject. His work is credited with spurring the creation of Orange County’s trauma network in 1980, plus systems in Los Angeles and San Diego counties and other communities.

The first of these studies appeared in 1979, when West and Dr. Donald Trunkey, the trauma director at San Francisco General Hospital, compared the number of trauma deaths at Trunkey’s hospital with similar cases in Orange County.

Based on a review of autopsy records, the two surgeons found that less than 1% of the San Francisco deaths were preventable, while 71% of the fatalities in Orange County--which had no trauma system--could have been averted.

The report sparked criticism from Orange County physicians, yet a similar study they conducted one year later found the problem to be even more serious. Several months later, county supervisors approved the creation of Southern California’s first trauma network.

Orange County Statistics

In 1983, West and Cales released a study showing that Orange County’s trauma system had cut the rate of preventable deaths to 9%. “It was,” Cales said, “the final proof that trauma care could make a difference in a region, and truly save lives.”

Today, by projecting the number of preventable trauma deaths in selected cities on a national level, West and other surgeons estimate that at least 15,000 Americans die needlessly from injuries each year. Some believe the number could be as high as 25,000.

Still, the growth of trauma care across America has been blocked by “professional egos and money,” according to Trunkey.

At first glance, the controversy is puzzling. Hospitals are competing as never before to fill their beds with paying customers, and many would like to offer an array of state-of-the-art services, including trauma care. Although only 5% to 8% of injured patients are trauma victims, many hospitals believe there are great profits to be made in hanging trauma center signs outside their emergency rooms.

But there is a catch. First, the officials who designate trauma centers in a given community often choose only a handful. And they usually require paramedics to take victims directly to the few trauma centers, bypassing non-trauma hospitals.

These two rules have sparked much of the opposition to trauma care. Hospitals don’t like government officials telling them they can’t offer a certain kind of program, and they rebel at the idea of ambulances speeding past their emergency rooms to more distant medical centers.

However, trauma surgeons believe these restrictions are essential.

Need Steady Stream

First, they say, trauma programs are expensive to operate. Hospitals need a steady share of patients to at least break even, and cannot do so if every medical center in town is competing for such a small pool of victims.

Second, trauma centers must accept all patients who are taken to their emergency rooms, including the poor. Without a constant flow of patients--the affluent along with the indigent--a trauma hospital could take a financial bath.

Finally, medical experts say trauma surgeons can best maintain and sharpen their skills by seeing a steady stream of patients. If a trauma center saw only a handful every year, the quality of emergency care in a community could decline.

Yet these arguments are rejected by many hospital administrators who fear they will lose patients to trauma centers, said Dr. David Boyd, a surgeon who helped establish the federal Office of Emergency Medical Services before it was disbanded in 1982.

Other administrators believe the prestige of their hospitals will plummet if they do not offer such care, he added. In some communities, hospitals that lost bidding wars to become trauma centers have sued to block competitors from offering such care.

Opposition also comes from doctors who have spent years developing specialties at selected hospitals and complain that a trauma system will “steal” patients away from them, Boyd said.

Medical Restrictions

Trauma care is also blamed for opening a Pandora’s box of restrictions on medical care. The notion that local government can limit the number of trauma centers, for example, “is seen as the first line of something that is threatening to hospitals and their financial future,” according to Stanley van den Noort, former dean of the College of Medicine at the University of California, Irvine.

Still other physicians believe the field of emergency medicine is making giant strides and has diminished the need for 24-hour trauma surgeons. Many of these new doctors believe they are just as qualified to treat most victims as trauma practitioners.

“The vast majority of patients who have life-threatening injuries from trauma do not go to the operating room. Most of those can be taken care of immediately . . . in the emergency department,” said Dr. Michael J. Bresler, president of the California Chapter of the American College of Emergency Physicians.

West strongly disagreed. “Every trauma study has shown that we lose thousands of people every year because surgeons aren’t available,” he said. “This argument is just plain wrong. It’s a prime roadblock to the improvement of emergency medicine.”

As the debate continues, battles over trauma care have broken out nationwide.

In Sacramento, an obscure public commission has been bitterly debating statewide guidelines for trauma care. The decision of the Emergency Medical Services Commission, which meets periodically in airport hotels, could profoundly affect the quality of emergency care in hospitals throughout California.

Surgeons on Premises

At the heart of the dispute is the so-called “in-house” rule, which requires that most trauma centers have surgeons on the premises around the clock. Such a standard “goes to the very core” of a modern trauma system, according to Dr. Frank Lewis, a commission member and surgeon at San Francisco General Hospital. However, emergency medicine doctors and hospital administrators have opposed the rule, saying it is costly and unnecessary.

Trauma systems in Los Angeles, Orange and San Diego counties have also seen their share of political and medical controversies.

In West Los Angeles, for example, officials at Santa Monica Hospital and Brotman Memorial Hospital in Culver City were angered two years ago when they were not selected to be trauma centers. Both hospitals launched campaigns to reverse the decision by county supervisors.

Brotman’s appeal was denied, but Santa Monica was allowed into the trauma system this summer after a campaign in which it hired attorneys, including former Los Angeles Dist. Atty. Robert Philibosian and attorney Douglas Ring, who was chief deputy to former Supervisor Baxter Ward.

Santa Monica officials--who said they wanted to fill a “critical” medical need on the Westside--hired the attorneys “to help us with the politics of this situation. . . . It’s costly but you have no other choice,” according to Leon Vargas, the hospital’s assistant vice president.

Elsewhere, there have been intense struggles to launch programs in Florida and Pennsylvania, plus complaints that hospital turf wars have compromised trauma care in New York, Washington, Phoenix and San Francisco, as well as Maryland and New Jersey.

West German Example

Amid such helter-skelter care, some trauma advocates believe the federal government should press for tough emergency medical standards in all 50 states. They point to West Germany, which has built a nationwide trauma system up and down the national highway system.

But a federal initiative seems unlikely, given the current political climate.

In 1982, budget cutters for former trauma patient Ronald Reagan ended a federal program that allocated money to states for emergency medical programs, including trauma care.

The former federal program, known as the Office of Emergency Medical Services, was launched in 1974 by Boyd, an Illinois surgeon. The outspoken doctor, who earlier had established trauma centers in his home state, approached his federal post with zeal, speaking to communities throughout the nation and supervising the distribution of nearly $300 million in grants.

Today, federal officials do not know if the emergency medical programs created by such largess are still operating or if they have been effective. “We pushed $300 million out the window . . .” Boyd said, “and now nobody knows what the situation is.”

Under the Reagan Administration, “the mandate is to look to the private sector and the professional sectors in our nation, to accept, use and improve those emergency medical care standards that were developed over the last 10 to 13 years,” said federal Health Services Administration official John D. Reardon, who was one of Boyd’s highest ranking aides.

Will trauma care ever become a nationwide reality?

Forced Change

Some experts, like San Francisco General’s Trunkey, believe the country will have only a few “islands of excellence” in emergency medical care until outside pressures--possibly from lawsuits--force medical standards to change.

“If you sue enough hospitals, if you sue enough doctors, then the system will change in order to protect itself,” said Trunkey, speculating that there may be a flurry of trauma lawsuits once patients and attorneys realize the dangers of sub-par emergency care.

Others speculate that pressures for change will come from insurance companies, who may balk at paying death benefits--or costly medical bills--for accident victims who might have lived or recovered more fully if they had received trauma care.

All trauma advocates believe that sweeping changes are not likely until the public realizes that people are dying unnecessarily and demands better medical care.

“When that information truly sinks in to the general public, especially through the media, it’s going to outrage a lot of people,” said Andrew McGuire, who directs the San Francisco Trauma Foundation, a nonprofit agency based at San Francisco General Hospital.

Inadequate care “is a volcano ready to erupt,” he added. “We’re dealing with a major public health problem, which is that you get injured somewhere and you don’t necessarily get good care.”

For Lanie Niemeyer--and thousands of other trauma victims who have survived--the issue is clear-cut. Looking back, the young woman who returned to school expressed amazement at her injuries and her recovery.

“I never imagined anything like this would ever happen to me,” she said. “A year ago if someone told me, ‘You’re going to go into a coma and you’re going to be brain-damaged, and still recover,’ I wouldn’t believe it. It’s incredibly hard to believe. But I am a miracle.”

A TRAUMA CASE TIMELINE

Hospitals designated as trauma centers cut the time needed to deliver emergency care--for those who can get there quickly. Across the nation, experts estimate that 15,000 trauma victims die every year from non-lethal injuries suffered in car accidents, shootings, stabbings and industrial accidents because trauma care is not available. Here is an account of what happened to one victim--Lainie Niemeyer--involved in an accident near a designated trauma care unit: 9:30 p.m. Lainie Niemeyer’s car is hit on Oct. 11, 1984, at Rosecrans and Prairie avenues in South Bay. 9:39 Members of rescue team from Hawthorne Fire Department arrive at scene, using “jaws of life” to pry Niemeyer from crumpled car. 9:46 Paramedics arrive and begin treatment. 10:13 Daniel Freeman Hospital alerted by radio base station at Hawthorne Community Hospital that Niemeyer is coming in. 10:19 Niemeyer arrives at Daniel Freeman trauma unit; two intravenous lines already inserted by paramedics. 10:21 Tests done to see if she has a broken neck, plus lab work, battery of tests. 10:24 Tests show Niemeyer has no broken spine or neck. 10:28 Catheter inserted; bloody drainage, internal bleeding suspected. 10:36 Chest X-ray. 10:37 Peritoneal lavage (belly tap) is positive; proof of internal bleeding. 10:38 Niemeyer still has difficulty breathing; she’s intubated, breathing tube put in. 10:41 Nasal/gastric tube inserted. 10:47 Chest tube inserted, pneumo-thorax problem detected. 11:04 Kidneys checked for bleeding; drainage. All the while, trauma team must slowly deflate and remove the MAST (military anti-shock trousers) put on Niemeyer at time of accident to stabilize her blood pressure. 11:50 By now, Niemeyer is on the ventilator breathing system; CT scan of head to see if neurosurgeon will be needed in the operating room. It turns out she has no brain emergency. 12:25 a.m. Niemeyer taken to surgery. 2:40 Surgery completed; stop bleeding from torn liver and spleen. Niemeyer then spends 19 days in intensive care unit. She’s transferred to rehab unit; discharged on Jan. 15, 1985. Enters New Pathways Program at Daniel Freeman for brain-rehab patients. Completes program in July, 1985.

Trauma Hospitals in the Region 1. Westlake Community Hospital 2. Henry Mayo Newhall Memorial Hospital 3. Antelope Valley Hospital Medical Center 4. Northridge Hospital Medical Center 5. Holy Cross Hospital 6. St. Joseph Medical Center 7. Santa Monica Hospital 8. UCLA Hospital 9. Cedars-Sinai Medical Center 10. Hollywood Presbyterian Medical Center 11. Childrens Hospital of Los Angeles 12. Huntington Memorial Hospital 13. Daniel Freeman Memorial Hospital 14. L.A. County/USC Medical Center 15. Methodist Hospital of So. California 16. Harbor/UCLA Medical Center 17. Martin Luther King Jr. Hospital 18. Presbyterian Intercommunity Hospital 19. Queen of the Valley Hospital 20. Pomona Valley Community Hospital 21. St. Mary Medical Center 22. Memorial Hosp. Medical Center of Long Beach 23. Fountain Valley Regional Hospital 24. Western Medical Center 25. UC Irvine Medical Center 26. Mission Community Hospital 27. Palomar Memorial Hospital 28. Scripps Memorial Hospital 29. Childrens Hospital and Health Center 30. Sharp Memorial Hospital 31. UC San Diego Medical Center 32. Mercy Hospital and Medical Center